Ertugliflozin/Steglatro Advice


Bec_22_Aus
 

 Hi everyone,

I am after feedback from those who have used Steglatro/ Ertugliflozin. How long has your horse been on it and how are you going?

 

My pony was on Steglatro for a period (6 months? Until blood levels were normal) and came off only to relapse and have to go back on. I’m concerned about the long term consequences and the risk of fatty liver. So would love to know stories of others who’ve been on it for a while. Pony is definitely more lazy when he is on this medication. 

 

My pony is not currently sore. 

Not on grass and follows a diet consistent with the recommendations of this page. 

Barefoot. 

No recent X-rays. 

Diagnosed with Cushings and EMS two years ago. 

Not overweight. 

From Australia. 

On Pergolide and Steglatro. 

 

Thanks in advance 😊

--
Bec in Australia, 2022


 

Hi Bec,

Welcome to the ECIR group.  As a new ECIR group member making the first post, you are sent a formal welcome which contains lots of good information.  We focus on diagnosis, diet, trim and exercise in both resolving and preventing IR related issues.  Dr. Kellon has been guiding those of us who are now using Steglatro, along with our veterinarians, so you may want to put your vet in touch with her directly.  I’m sure she must have some sort of informational packet she passes along.  While I don’t have any horses using those drugs, I have noted that there needs to be regular attention paid to triglyceride levels.  Like other drugs used to decrease insulin, this isn’t a treatment which cures a ‘disease’ but rather  a means of decreasing insulin to a safe level while the drug is in place.  Ceasing the drug did not cause a ‘relapse’ as much as a return to your pony’s ‘normal’, given the pony’s genetics and how it is being managed.  Some ponies just cannot be managed by diet alone and need extra help, whether it’s with metformin or Steglatro type drugs.

We would like to see your blood work reports as a part of your case history.  What follows is our lengthy informational welcome.  A lot of it will be familiar to you, I’m sure.

The ECIR Group provides the best, most up to date information on Cushing's (PPID) and Equine Metabolic Syndrome (EMS)/Insulin Resistance (IR). Please explore our website where you'll find tons of great information that will help you to quickly understand the main things you need to know to start helping your horse. Also open any of the links below (in blue font) for more information/instructions that will save you time.

Have you started your Case History? If you haven't done so yet, please join our case history sub-group. We appreciate you following the uploading instructions so your folder is properly set up with the documents inside. Go to this CH message with info on how to use various devices and forms. If you have any trouble, just post a message to let us know where you are stuck. 

Orienting information, such as how the different ECIR sections relate to each other, message etiquettewhat goes where and many how-to pages are in the Wiki. There is also an FAQs on our website that will help answer the most common and important questions new members have. 

Below is a general summary of our DDT/E philosophy which is short for Diagnosis, Diet, Trim and Exercise.

 

DIAGNOSIS: There are two conditions dealt with here: Cushings (PPID) and Equine Metabolic Syndrome (EMS)/Insulin Resistance (IR). These are two separate issues that share some overlapping symptoms. An equine may be either PPID or EMS/IR, neither or both. While increasing age is the greatest risk factor for developing PPID, IR can appear at any age and may have a genetic component. Blood work is used for diagnosis as well as monitoring the level of control of each.

PPID is diagnosed using the Endogenous ACTH test, while EMS/IR is diagnosed by testing non-fasting insulin and glucose.

The fat-derived hormone leptin is also usually abnormally elevated in insulin resistance but because there are many other things which can lower or increase leptin ECIR is not recommending routine testing for this hormone. Leptin is the hormone that says "stop eating".

In Europe, adiponectin is tested instead of leptin. Adiponectin helps regulate glucose and fat burning, and maintain insulin sensitivity. Low levels are associated with EMS. It has come to be preferred over leptin because it is not influenced by things like weight or exercise, and also because it was the only factor other than insulin levels that predicted laminitis risk

*Before calling your vet to draw blood for tests, we suggest saving time and wasted money by reading these details and then sharing them with your vet so that everyone is on the same page regarding correct testing and protocols.

*Please remember to request copies of the results of all the tests done rather than just relying on verbal information. Your vet should be able to email these to you. If you have previous test results, please include those as well. All should go in your CH, but if you are having any trouble with the CH, just post in the messages for now. 

Treatment: EMS is a metabolic type - not a disease - that is managed with a low sugar+starch diet and exercise (as able). The super-efficient easy keeper type breeds such as minis, ponies, Morgans, Arabs, Rockies are some of the classic examples. PPID is a progressive disease that is treated with the medication pergolide. Some, but not all, individuals may experience a temporary loss of appetite, lethargy and/or depression when first starting the medication. To avoid this "pergolide veil" (scroll down for side effects), we recommend weaning onto the drug slowly and the use of the product APF. The best long term results are seen when the ACTH is maintained in the middle of the normal range at all times, including during the annual seasonal rise. To accomplish this, the amount of medication may need to increase over time. Neither condition is ever "cured", only properly controlled for the remainder of the equine's life. If your partner is both PPID and IR then both medication and diet management will be needed. 

DIET: Almost all commercial feeds are not suitable - no matter what it says on the bag. Please see the International Safe Feeds List for the safest suggestions.

No hay is "safe" until proven so by chemical analysis. The diet that works for IR is:

  • low carb (less than 10% sugar+starch)
  • low fat (4% or less) 
  • mineral balanced  

We use grass hay, tested to be under 10% ESC + starch, with minerals added to balance the excesses and deficiencies in the hay, plus salt, and to replace the fragile ingredients that are lost when grass is cured into hay, we add ground flax seed and Vitamin E. This diet is crucial for an EMS/IR horse, but also supports the delicate immune system of a PPID horse. 

*Until you can get your hay tested and balanced we recommend that you soak your hay and use the emergency diet (scroll down for it).  The emergency diet is not intended for long term use, but addresses some of the most common major deficiencies. Testing your hay and getting the minerals balanced to its excesses and deficiencies is the best way to feed any equine (look under the Hay Balancing file if you want professional help balancing). If you absolutely cannot test your hay and balance the minerals to it, or would like to use a "stop gap" product until you get your hay balanced, here's a list of "acceptable" ration balancers

There is a lot of helpful information in the start here folder so it is important you read all the documents found there. The emergency diet involves soaking your untested hay for an hour in cold water or 30 minutes in hot water. This removes up to 30% of the sugar content, but no starch. Starch is worse than sugar since it converts 100% to glucose while sugar only converts 50%, so starch causes a bigger insulin spike. Make sure you dump the soaking water where the equine(s) can't get to it. 

What you don't feed on the EMS/IR diet is every bit as, if not more important than, what you do feed! No grass. No grain. No sugary treats, including apples and carrots. No brown/red salt blocks which contain iron (and sometimes molasses) which interferes with mineral balancing, so white salt blocks only. 

No products containing molasses. No bagged feeds with a combined sugar and starch of over 10% or starch over about 4%, or fat over about 4%. Unfortunately, even bagged feeds that say they are designed for IR and/or PPID equines are usually too high in sugar, starch and/or fat. It’s really important to know the actual analysis and not be fooled by a name that says it is suitable for EMS/IR individuals.

We do not recommend feeding alfalfa hay to EMS/IR equines as it makes many of them laminitic. Although it tends to be low in sugar, many times the starch is higher and does not soak out. Additionally, protein and calcium are quite high, which can contribute to sore footedness and make mineral balancing very difficult.

TRIM: A proper trim is toes backed and heels lowered so that the hoof capsule closely hugs and supports the internal structures of the foot. Though important for all equines, it's essential for IR and/or PPID equines to have a proper trim in place since they are at increased risk for laminitis. After any potential triggers are removed from the diet, and in PPID individuals, the ACTH is under control, the realigning trim is often the missing link in getting a laminitic equine comfortable. In general, laminitic hooves require more frequent trim adjustments to maintain the proper alignment so we recommend the use of padded boots rather than fixed appliances (i.e. shoes, clogs), at least during the initial phases of treatment.

Sometimes subclinical laminitis can be misdiagnosed as arthritis, navicular, or a host of other problems as the animal attempts to compensate for sore feet. 

You are encouraged to make an album and post hoof pictures and any radiographs you might have so we can to look to see if you have an optimal trim in place. Read this section of the wiki for how to get a hoof evaluation, what photos are needed, and how to get the best hoof shots and radiographs.

EXERCISEThe best IR buster there is, but only if the equine is comfortable and non-laminitic. An individual that has had laminitis needs 6-9 months of correct realigning trims before any serious exercise can begin. Once the equine is moving around comfortably at liberty, hand walking can begin in long straight lines with no tight turns. Do not force a laminitic individual to move, or allow its other companions to do so. It will begin to move once the pain begins to subside. Resting its fragile feet is needed for healing to take place so if the animal wants to lay down, do not encourage it to get up. Place feed and water where it can be reached easily without having to move any more than necessary. Be extremely careful about movement while using NSAIDs (bute, banamine, previcox, etc.) as it masks pain and encourages more movement than these fragile feet are actually able to withstand. Additionally, NSAIDs (and icing) do not work on metabolic laminitis and long term NSAID use interferes with healing. Therefore, we recommend tapering off NSAIDs after the first week or so of use. If after a week's time your equine's comfort level has not increased, then the cause of the laminitis has not been removed and keeping up the NSAIDs isn't the answer - you need to address the underlying cause.

 

There is lots more information in our files and archived messages and also on our website. It is a lot of information, so take some time to go over it and feel free to ask any questions. If you are feeling overwhelmed, don't worry, you will catch on, and we are always here to help you! Once you have your case history uploaded, we can help you help your equine partner even better.

For members outside North America, there are country specific folders in the files and many international lists in the wiki to help you find local resources.

If you have any technical difficulties, please let us know so we can help you. 

 
--
Martha in Vermont
ECIR Group Primary Response
July 2012 
 
Logo (dec. 7/20/19), Tobit(EC) and Pumpkin, Handy and Silver (EC/IR)

Martha and Logo


 
 


Sheri and Peaches
 

Hi, Bec.  My 11yo AQHA mare, Peaches, has been on Steglatro for 12 months, with good results.  She is IR, but not PPID; sound; no prior laminitis.  Diet / hay soaking / testing / dry lot / exercise were not controlling her insulin, which had started to creep upwards.  Having previously lost a horse to the IR/PPID battle despite years of hay soaking / balancing / dry lot, etc., I decided to start Peaches on Steglatro as a preventative measure.  

I am far more concerned about sub-clinical laminitis than liver damage.  Fortunately, Peaches' GGT (liver) has been normal while on Steglatro.  After 10 months on Steglatro, Peaches finally started losing weight for the first time ever.  Her insulin has been stable and normal while on the Steglatro.  Over the winter, her insulin crept up a little, which correlated with reduced exercise.  When I first started Steglatro, her Triglycerides started to creep up, but then they dropped back into normal range. GGT has been stable and normal, except for one slightly elevated test which then dropped back into normal range. 

Peaches' most recent bloodwork showed slightly elevated TG, again, which seems to correlate with when I ran out of L-Carnitine.  I had not been very consistent with that supplement (it's sticky and messy).  And, I had been feeding ALCAR, when L-Carnitine would have been the better choice.  For the past two months, I have been very religious about her daily tablespoon of L-Carnitine.  I am assuming that her TG will drop back into normal range with the blood draw next week.

Ten months into the Steglatro, after Peaches lost the excess weight, I noticed that her energy was lower.  She started complaining about working on hills and was getting tired more quickly.  So, for the past two months, I have been skipping her Steglatro on the days that she gets exercised.  And, I am making a point to exercise her more vigorously.  I will learn more with her blood work next week and will then decide whether to continue this on again / off again experiment.  So far, her energy levels have returned to normal, so I am hoping that her blood results will support this program.  My understanding is that a partial dose is ineffective, so I am better off with the all-or-none dosing.  Of course, I have continued my routine hay soaking / testing / balancing / dry lot, etc.

My biggest complaint with Steglatro is the increased urine output.  I use corn pellet bedding beneath her pine shavings for its excellent absorbency / clumping action.  But, Peaches will eat the corn pellets if they are not soaked into a powder before being added to her bedding.  Most of the time, Peaches chooses to urinate in her stall, instead of her dry lot.  I would love to lock her out there full time, but I feed my horses inside their stalls on the rubber mats to avoid sand colic.  And, they like to nap in front of their fans. 

Dr. Kellon has been a great resource.  She emailed some guidance to me and my local vet.  Also, one of my vets had previously spoken with Dr. Frank at Tufts during their Steglatro study.  I learned of the drug from this group and an Australian vet that was using it on her own horses. 

--
Sheri P in IL 2021
Peaches Case History & files:  https://ecir.groups.io/g/CaseHistory/files/Sheri%20and%20Peaches


LJ Friedman
 

increased urine output means the medicine is working so that should be something that pleases you. i  Remember when Jesse started invokana  , I had to pay for additional bedding for the stall. Do you think it’s a good idea to skip the medicine for that one day for energy increase? 
--
LJ Friedman  Nov 2014 Vista,   Northern  San Diego, CA

Jesse( over the rainbow) and majestic ‘s Case History 
Jesse's Photos

 


Eleanor Kellon, VMD
 

Sheri,

How much exercise is she getting? Do you change her feeding on those days? Are you still soaking hay? What is her diet?

You are absolutely right that lower doses are not useful.  The -flozin drugs are like exercise in a pill, causing mobilization of fats to compensate for low glucose stores.  The fatigue you are encountering is because those mobilized fats cannot be burned when oxaloacetate levels, which can only come from carbohydrate, are too low. Working her harder won't help.

You are on the right track with on again/off again but also have to have sufficient available carbohydrate to fuel the exercise and fat burning.

--
Eleanor in PA

www.drkellon.com 
EC Owner 2001